#Ishikawa diagram
Ishikawa Diagram (Fishbone). The undisputed analytical skeleton grafically exposing all tendrils branching into a catastrophe. Clusters the chaos into five neat bones: People, Rigs, Methods, Supplies, and Biosphere.
"Learning from Mistakes" or How to Conduct a High-Quality Incident Investigation
Implementation of the A3 incident investigation methodology to shift from blame-seeking to systemic root cause analysis. The practice includes a step-by-step fact-gathering algorithm, application of analysis tools (timeline, cause tree, Ishikawa diagram, barrier diagram), and evaluation of corrective actions using an effectiveness-cost matrix.
HSE Incident Investigation: Goals, Objectives, Methods
Implementing a systemic approach to investigating all incidents, including micro-injuries, focusing on finding root causes instead of assigning blame. The practice involves the sequential application of analytical tools (5W1H, 4M analysis, "5 Whys") by cross-functional working groups and mandatory horizontal scaling of corrective measures to adjacent departments.
Incident Management
The incident management system at Danone, which includes investigating all incidents (including micro-injuries and near-misses) using a combination of 5M and "5 Whys" methods. The practice covers involving contractors on an equal footing with full-time employees and developing a neural network to forecast future incidents based on large datasets.